Conventional Evaluation and Treatment of Burning Mouth Syndrome

By Susan E. Sklar, M.D.
The first step in treating Burning Mouth Syndrome is a thorough evaluation. A physician must make the diagnosis initially. This because there are other diseases and side effects of medicines that can occur with similar symptoms.

Do You Have Burning Mouth Syndrome?

Are you plagued with burning in your mouth or tongue?  Does it occur every day?  Has it gone on for four to six months?  Have you been to many doctors and dentists who say everything looks normal?  If so, you likely have Burning Mouth Syndrome.

Burning Mouth Syndrome is a chronic pain condition. It is a neuropathy. This means that a nerve becomes inflamed and sends messages to the brain that something is wrong. This shows up as either burning pain, tingling, a metallic taste in the mouth or a feeling of dry mouth.

Patients end up seeing a wide variety of healthcare practitioners before they receive a diagnosis.  The patients we see it the Sklar Center have often seen a dentist, ear nose and throat doctor, oral surgeon, allergist, primary care doctor, neurologist, rheumatologist and sometimes an infectious disease doctor. Very few doctors have heard of Burning Mouth Syndrome. And fewer doctors know how to treat Burning Mouth Syndrome.  This fact makes it much more difficult for patients. Estimates show that it takes two to three years to make the diagnosis. Moreover, before patients learn the diagnosis, they have seen an average of four to five doctors.

Who Gets Burning Mouth Syndrome?

Burning Mouth Syndrome mainly affects women, particularly after the menopause. The highest numbers are in women aged 60 to 69.  90% of the people who have Burning Mouth Syndrome are perimenopausal or menopausal women. This shows a high likelihood that hormones play a role.  Men who experience burning sensations in their mouths are affected far less than women, 1/3 to 1/10 as often. The average age for Burning Mouth Syndrome in females is 64.  For men, it is older.  It is rare to find burning mouth syndrome in females under age 30 and in males under age 40. [1]

What Causes Burning in the Mouth?

There are many conditions which can cause burning in the mouth. A physician must make a thorough evaluation before making the diagnosis of Burning Mouth Syndrome. Some of the causes are what follows:

Medications: The first thing to look at is current medications. Medications can cause the following symptoms: burning in the mouth, low saliva levels, and dry mouth.  There are medications that can cause these symptoms:

  • Antihistamines (allergy medications)
  • Blood pressure medications
  • Medications for cardiac arrhythmia (irregular heartbeat)
  • Benzodiazepine sedatives like Xanax and Ativan

The most implicated medications are high blood pressure medications principally those that act on the renin-angiotensin system. These include captopril, enalapril and lisinopril.[2]

Nutritional Deficiencies can cause Burning Mouth: Certain vitamin and mineral deficiencies can cause neurologic problems like Burning Mouth Syndrome. These are lack of:

  • Vitamins: B2, B6, and B12, folate
  • Minerals: Iron, zinc, and magnesium

Hormone Deficiencies can be a cause: 90% of the patients with Burning Mouth Syndrome are peri-menopausal and menopausal women.  Multiple hormone deficiencies occur at this time of life.

  • Estrogen deficiency leads to increased inflammation, which is the underlying process of neurologic pain
  • Progesterone at this stage of the life cycle means the loss of an important protection for the brain and nerves.
  • DHEA (dehydroepiandosterone) is an important nerve protector.
  • Pregnenolone loss means more vulnerability for delicate nerve cells.
  • Low thyroid function has been linked to Burning Mouth Syndrome also.

Thrush is a yeast infection: A yeast infection from Candida on the tongue can cause burning.  Usually the tongue is coated white or gray.  One study showed that treatment with a topical antifungal medication in the mouth helped 2/3 of the subjects in the study.[3]

Diabetes and Other Causes of Nerve Dysfunction and Disease called neuropathy can be a cause:

  • Diabetics are known to have increased risk of neuropathy with burning in the legs and feet. They also have increased risk of Burning Mouth Syndrome.
  • Sarcoidosis is a disease of chronic inflammation.
  • Celiac disease caused by intolerance to gluten can cause neuropathy.
  • Arsenic toxicity caused by poisonous metals.
  • HIV/AIDS caused by a virus that blocks immunity and attacks nerves.

Viral Infections may be involved: Many viral infections cause blisters in the mouth which can leave pain after healing.  It is important to note that these viral infections can cause pain even if blisters are not present.[4] Here is a list of viral infections that can cause pain.

  • Herpes infections
  • Varicella zoster (which causes shingles)
  • Epstein-Barr infection,
  • Human Herpes Virus 6
  • Cytomegalovirus

Autoimmune Disorders also cause pain. Autoimmune disorders are diseases where the body attacks its own tissues. These diseases can cause similar symptoms to Burning Mouth Syndrome.  Autoimmune diseases can cause dry mouth, pain, and burning in the mouth.

  • Sjogren’s syndrome causes dry mouth and eyes.
  • Systemic Lupus Erythematosus also causes dry mouth and eyes.
  • Bechet’s disease causes sores in the mouth and elsewhere on the body. It may be an autoimmune disorder.

Mast Cell Activation Syndrome is another cause. Immune cells called mast cells become active during allergic reactions normally.  When they are overactive, Burning Mouth can result.  Dr. Lawrence Afrin compiled a study of women with Burning Mouth Syndrome. In his study, most patients improved when given medications that stabilize mast cells.  These medications are antihistamines and stomach acid blockers.  Some causes of Mast Cell Activation Syndrome can be mold toxicity and Lyme disease.[5]

Gastro-esophageal Reflux/Laryngeal-pharyngeal Reflux is common: This is a disease caused by loosening of the lower esophageal sphincter. This allows reflux of gastric contents into the esophagus, throat  and mouth, causing burning pain.

What is the Evaluation for Burning Mouth Syndrome?

Initially, a physician examines the mouth and tongue.

  • Is there a white coating (a sign of thrush)
  • Are there tiny blisters (possible herpes or shingles infection)
  • Are there white patches (could be Lichen Planus) which is a sign of a viral infection and low thyroid?
  • Is there low salivary flow? A dentist who specializes in this problem can evaluate salivary flow.

Laboratory testing:

  • Cultures (swab tests) for herpes and other viral infections as well as a culture for yeast infection.
  • Blood tests for vitamin and mineral status.

Vitamin B2, B6, B12 and folate. red blood cell magnesium, iron, total iron binding capacity, percent saturation, and ferritin levels

  • Blood tests can show prior viral infection which may still be lurking in the nerve roots and causing pain.

Test blood titers for these: Herpes type 1 and 2, Human Herpes Virus 6, Epstein-Barr Cytomegalovirus, and Varicella Zoster (shingles)

  • Blood test for autoimmune diseases:

Anti-nuclear antigen, Rheumatoid Factor, and other tests for Sjogren’s and Systemic Lupus Erythematosus (SS-A and SS-B). If test results are clear and the tongue and mouth look completely normal, but there is pain, a diagnosis of Burning Mouth Syndrome is certain.

It’s Not in Your Head:

Burning Mouth Syndrome is a central neuropathic pain condition.  This means that the nerves connecting your tongue sensations to your brain are not functioning correctly. It also means that the problem is in your brain cells as well as the nerves to your tongue and mouth.  No one knows exactly why this happens.

Making a diagnosis can be difficult

Usually, the biopsy looks normal. However, special stains show an overall reduction in nerve fibers in the lining of the mouth of Burning Mouth Syndrome patients. This is compared to people who don’t have Burning Mouth Syndrome. Also, there is degeneration of the long, thin connector nerves called the axons. In addition, certain pain receptors and nerve growth factors were different in the tongues of Burning Mouth patients from healthy subjects. There are differences in proteins that are involved in pain feelings between Burning Mouth patients and controls. These studies show that there is a factual basis for the dysfunction of nerves in Burning Mouth Syndrome.  You are not imagining it!

There are Differences in Brain Function

There are also differences in the brains of Burning Mouth sufferers. They have lower dopamine. Dopamine is a pain modulating brain chemical.  This could also be a contributor to the chronic pain in Burning Mouth Syndrome.

There are Theories about the Cause of Burning Mouth Syndrome

Hormones There are several theories about the cause of Burning Mouth Syndrome.  Since 90% of the people who have this condition are peri-menopausal and menopausal women, hormone decline is one possible cause.  We also know that stress and anxiety are associated with worse pain in Burning Mouth Syndrome.  Doctors used to think it was “all in the head.”  However, we know that there are many physiological changes that increase pain when there is emotional stress.

Mast Cell Activation Another theory is mast cell activation. This is a condition where a type of white blood cell called mast cells release irritating and inflammatory chemicals that cause nerve pain.

Lack of Neuroactive Chemicals What we do know about neuropathic pain is that they persist because there are not enough nourishing chemicals for nerve growth and repair.  In addition, the researchers find that the nerves are inflamed.   This adds up to pain, burning, taste abnormalities, and feelings of dryness.

What are the Standard Treatments for Burning Mouth Syndrome?

There are many treatments for Burning Mouth Syndrome.  Here are the most prescribed medications in traditional medical treatment.

Topical Capsaicin (hot peppers): According an article published in American Family Physician, a mouth rinse with cayenne extract can decrease pain.[6] The capsaicin is the chemical that makes the peppers hot. This chemical attaches to the vanilloid pain receptors and desensitizes them.  This means that these receptors stop sending pain messages to your brain.  Yes, hot peppers may help relieve pain in those suffering from burning mouth syndrome! One study showed that after a year of treatment, 20-78% of people improved.[7] There may be increased burning initially but after extended use, the pain receptors become numbed and pain decreases.  About one third of patients are not able to tolerate this treatment and move on to another.

Topical Clonazepam: This is a prescription sedative in same family as Librium and Valium. They are sedative medications.  They also can be addictive,  When melted on the tongue rather than swallowing, it brings relief to some people with Burning Mouth Syndrome.  Clonazepam calms the inflamed nerves feeding the tongue.  It seems to work on the inflammation pathways rather than just sedating people. A study from Spain (8) found that sucking on a 1 mg clonazepam tablet for 3 minutes after every meal effectively reduced pain, abnormal sensations, dry mouth and altered sense of taste in patients with Burning Mouth Syndrome.  After sucking the tablet for 3 minutes and holding saliva in the mouth in the areas of pain, the undissolved tablet is spit out.  In the Spanish study 40% of people had significant relief of pain and 20% had complete relief. Sucking and spitting out the tablet leads to less sedation. Thus, there is less chance of addiction.

Topical Mouth Moisturizers: Products like Biotene claim to moisten the mouth and supply relief for the dry mouth aspect of Burning Mouth Syndrome.  Most patients use it, but it does not seem to bring about dramatic relief.

Anti-depressant medications: Clinicians often proscribe old-fashioned anti-depressants in the tricyclic family of medications pain relief. These medications are amitriptyline and nortriptyline.  They work by blocking norepinephrine and serotonin, two nerve transmitting chemicals. This is supposed to decrease pain.  A recent review of these medications showed modest benefits and high side effects in 90% of patients.  These side effects include, drowsiness, dizziness, dry mouth, blurred vision, constipation, weight gain, or trouble urinating. In addition, these medications can make dry mouth worse.[9]

 Anti-seizure medication: Many physicians proscribe medications like gabapentin for relief of chronic nerve pain. Which makes sense because Burning Mouth Syndrome is a nerve pain disease. These medications have side effects of fuzzy thinking, dizziness, sleepiness, and fatigue.  Lacosamide (Vimpat) is a newer anti-seizure medication that has helped some patients, but it also has problematic side effects like gabapentin.

Supplements for the Treatment of Burning Mouth Syndrome: Alpha Lipoic Acid in its capsule form is known to be effective for diabetic nerve pain and tingling.  Some studies show that it relieves the pain of Burning Mouth Syndrome. Although many of these studies have not been reproducible which casts some doubt on the effectiveness.  Alpha Lipoic Acid is worth trying since it has virtually no side effects.[10] If blood testing shows lower than optimal levels of vitamins and minerals supplementation can be beneficial. In functional medicine, we consider the standard Minimum Daily Requirement mostly to be insufficient. We would begin supplementation with the B vitamins and minerals such as iron, zinc, and magnesium. Some patients do well with supplementation of the micronutrients such as, boron, zinc, manganese, copper, and molybdenum.

Low Level Laser: Low-level laser radiation has pain relieving, anti-inflammatory, and tissue repair actions. Some studies have verified that low-level laser therapy (LLLT) can be effective in reducing the burning mouth symptoms of patients with BMS. Controlled trials investigating the effects of LLLT on BMS are still rare.  Study results are mixed.  One study[11] using laser three times a week showed a significant decrease in pain and an improvement in quality of life measures.  The placebo group improved also but treatment group showed more benefit. Other studies have shown small pain improvements but no improvement in quality of life.

Cognitive Behavioral Therapy: This is a form of talk therapy which helps to reframe negative thoughts and relieve stress.  Studies with Burning Mouth Syndrome show significantly decreased pain in people who underwent this type of therapy either short term (three sessions) or longer term (10-15 sessions). This points to the significant effect of stress in Burning Mouth Syndrome and other chronic pain syndromes.  Stress sets off a whole inflammatory chemical cascade. With what you now know about inflammation and neuropathic pain, you can see why stress makes your pain worse.

And it’s NOT in your head.

Contact Us for More Information and to Get Help.

Resources

  1. David Mock & Deepika Chugh Burning Mouth Syndrome International Journal of Oral Science 01 March 2010 LINK: Burning Mouth Syndrome
  2. Andy Wolff, Revan Kumar Joshi , Jörgen Ekström, Doron Aframian, Anne Marie Lynge Pedersen, Gordon Proctor, Nagamani Narayana, Alessandro Villa, Ying Wai Sia, Ardita Aliko, Richard McGowan, Alexander Ross Kerr, Siri Beier Jensen, Arjan Vissink, Colin Dawes A Guide to Medications Inducing Salivary Gland Dysfunction, Xerostomia, and Subjective Sialorrhea: A Systematic Review Sponsored by the World Workshop on Oral Medicine VI National Center for Biotechnology Information 2017 Mar;17(1):1-28 LINK: A Guide to Medications Inducing Salivary Gland Dysfunction, Xerostomia, and Subjective Sialorrhea: A Systematic Review Sponsored by the World Workshop on Oral Medicine VI
  3. Jae Hyung Kim, Hyunjung Kim, Kwang Yoon Jung, Seung-Kuk Baek Usefulness of Treatment with Topical Antifungals in Burning Mouth Syndrome Korean J Otorhinolaryngol-Head Neck Surg 2019; 62(12): 726-730. December 21, 2019 LINK: Usefulness of Treatment with Topical Antifungals in Burning Mouth Syndrome
  4. Maria A Nagel and Don Gilden Burning mouth syndrome associated with varicella zoster virus BMJ Case Rep. 2016; 2016 2016 Jul 5 LINK: Burning mouth syndrome associated with varicella zoster virus
  5. Lawrence B Afrin Burning Mouth Syndrome and Mast Cell Activation Disorder Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011 Apr;111(4):465-72 LINK: Burning Mouth Syndrome and Mast Cell Activation Disorder
  6. MIRIAM GRUSHKA, M.SC., D.D.S., PH.D., JOEL B. EPSTEIN, D.M.D., M.S.D, MEIR GORSKY, D.M.D. Burning Mouth Syndrome Am Fam Physician 2002 Feb 15;65(4):615-621. LINK: Burning Mouth Syndrome
  7. L Azzi, F Croveri, L Pasina, M Porrini, R Vinci, M Manfredini, L Tettamanti, A Tagliabue, J Silvestre-Rangil, F Spadari A “burning” Therapy for Burning Mouth Syndrome: Preliminary Results With the Administration of Topical Capsaicin J Biol Regul Homeost Agents Apr-Jun 2017;31(2 Suppl 1):89-95. LINK: A “burning” Therapy for Burning Mouth Syndrome: Preliminary Results With the Administration of Topical Capsaicin
  8. Bruce Jancin IHC: Sucked clonazepam douses burning mouth syndrome Internal Medicine News August 1, 2015 LINK: IHC: Sucked clonazepam douses burning mouth syndrome
  9. Takayuki Suga, Miho Takenoshita, Takeshi Watanabe, Trang TH Tu, Lou Mikuzuki, Chaoli Hong, Kazuhito Miura, Tatsuya Yoshikawa, Takahiko Nagamine, and Akira Toyofuku Therapeutic Dose of Amitriptyline for Older Patients with Burning Mouth Syndrome Neuropsychiatr Dis Treat. 2019; 15: 3599–3607. LINK: Therapeutic Dose of Amitriptyline for Older Patients with Burning Mouth Syndrome
  10. Begoña Palacios-Sánchez, Luis-Alberto Moreno-López,corresponding author Rocío Cerero-Lapiedra, Silvia Llamas-Martínez, and Germán Esparza-Gómez Alpha lipoic acid efficacy in burning mouth syndrome. A controlled clinical trial Med Oral Patol Oral Cir Bucal. 2015 Jul; 20(4): e435–e440. LINK: Alpha lipoic acid efficacy in burning mouth syndrome. A controlled clinical trial
  11. Juliana Cassol Spanemberg, José López, Maria Antonia Zancanaro de Figueiredo, Karen Cherubini, Fernanda Salum Efficacy of low-level laser therapy for the treatment of burning mouth syndrome: a randomized, controlled trial SPIE Digital Library 11 September 2015 LINK: Efficacy of low-level laser therapy for the treatment of burning mouth syndrome: a randomized, controlled trial

Download Dr. Sklar’s Free Ebook